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ECHO Ontario Chronic PainBootcamp – OPIOID CHALLENGE

All About Opioids: Tapering, Rotating and The Spectrum of Opioid Use

Friday, December 7, 2018

Andrew J Smith, MDCM

Medical Lead,

Interprofessional Pain and Addiction Recovery Clinic

Staff Physician, Neurologist, Pain and Addiction Medicine

Centre for Addiction and Mental Health, Toronto

John Flannery, MD, FRCPC

Medical Director of the Musculoskeletal

Rehabilitation Program at

Toronto Rehabilitation Institute

Disclosures

• Presenters: John Flannery & Andrew Smith

• Conflicts of Interest: None

2017 Canadian Opioid Guideline Recommendation #9

For patients with chronic noncancer pain who are currently using more than 90 mg morphine equivalents of opioids per day or more, we suggest tapering opioids to the lowest effective dose, potentially including discontinuation, rather than making no change in opioid therapy (WEAK recommendation)

• Remark: Some patients may have a substantial increase in pain or decrease in function that persists for more than one month after a small dose reduction, tapering may be paused or potentially abandoned in such patients.

2017 Canadian Opioid Guideline Recommendation #9

• Evidence (WEAK recommendation)

• PICO: patients with persistent CNCP on opioid therapy

• tapering vs. same opioid dose

• Two studies, total n=73

• Effect on pain uncertain

• very low quality evidence

• Success of tapering may be high

• definitions of success differed, low quality

NB HARMS ~successful tapering may reduce opioid-related harms

CNCP: Chronic Non Cancer Pain

Rationale for Opioid Tapering

• Evidence suggests that tapering after a failed opioid trial improves pain, mood, and functioning.

• Slow tapering is far safer than rapid tapering or abrupt cessation: Abrupt cessation will trigger severe withdrawal, which can have serious consequences:

• Withdrawal can also lead patients seek illicit sources of opioids, which can result in accidental exposure to fentanyl.

• Abrupt cessation can cause severe depression and suicidal ideation

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• Patient has persistent severe pain and pain-related disability despite a therapeutic opioid dose

• Patient is on an unusually high dose for the pain condition (well above 90 mg MEQ in a patient with mechanical low back pain).

• Patient has a complication from opioid therapy, such as sleep apnea, sedation, or dysphoria.

• Patient has suspected opioid use disorder and and refuses opioid maintenance therapy with methadone or buprenorphine/naloxone.

• Opioid induced hyperalgesia, tolerance, inter-dose withdrawal

• Potential harms (depression, sleep apnea, hypogonadism)

Reasons to Consider TaperingSituations to be careful with opioid tapering

• Pregnancy

• Unstable coronary artery disease

• Unstable psychiatric condition

Motivational approach to opioid tapering• Ask about the upsides and downsides from the

patient’s perspective

• Reflect any responses and emotions • “so your opioids are just take the edge off your pain”• “so you are worried about what these are doing to your body”

• Listen carefully, then link together pros and cons (if any)

• “on the one hand, you aren’t getting much benefit and you are worried about all the risks related to opioids, BUT you are scared about withdrawal”

• Ask “permission” to provide information • Individualize benefits and risks to review with patients • Plan for dose reductions• Withdrawal management• Talk about what other patients say/experience

Murphy et al. 2018CFP 2018; 64:584-587

What to Tell The Patient

• You are tapering the dose to prevent future harms (e.g., falls) and to improve the patient’s mood and well-being (e.g., energy and sleep).

• EDUCATION: Tapering does not necessarily increase pain – it may actually improve it:

• Opioids often stop working after many months or years.• Opioids can even make pain worse by lowering the pain threshold.

• Explain that you are not necessarily going to stop the opioids altogether, but will lower the dose to a level which improves mood and function while still keeping the pain manageable.

Tapering: Actively Engage The Patient Tapering: Actively Engage The Patient

• Explain that you will be lowering the dose gradually, and that you will adjust the rate of the taper according to how the patient is doing.

• Discuss benefits of tapering, that pain and function will improve

• Share success stories

• Normalize apprehension and provide support and frequent follow-up

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• Optimize non-opioid strategies for pain management

• Set realistic functional goals

• Optimize psychosocial support

• Create a schedule of dose reductions and follow-up

• Provide a list of withdrawal symptoms and strategies to manage each symptom including emerging pain (NO MAGICAL THINKING)

• Give a telephone number or email to reach your or a member of your team if they have questions or concerns during the taper

Tapering: Prepare The Patient for TaperingOpioid withdrawal (days,weeks, months or years)

Symptoms

• PAIN: headaches, muscle aches, joint aches, abdominal cramps

• SLEEP: insomnia, fatigue

• FLU-LIKE: sweats, chills, malaise

• GI: diarrhea, nausea and vomiting

• Psychomotor agitation

• Irritability

• Goose bumps

Signs

Management of opioid withdrawal

Non-pharmacological• Education

• Reassurance (Not life-threatening)

• Ongoing support end encouragement

• Involve the pharmacist

• Relaxation

• Mindfulness

• Exercises

Pharmacological• Melatonin 3mg for insomnia

• Nabilone 0.25mg qhs for pain, N/V, insomnia and anxiety

• Clonidine for anxiety, jitters, sweats and chills

• NSAIDs or acetaminophen for muscle pain

• Loperamide for diarrhea and stomach cramps

• Gabapentin or pregabalin for severe anxiety

• DO NOT USE ALCOHOL OR BENZOS

Opioid Tapering Protocol

Provide patient with naloxone kit

Provide harm reduction education

Dispense opioids frequently in small quantities (as often

as daily)

Taper by 10% every 2-4 weeks…May slow down when <

50% of original dose

Never reverse course

Frequent follow up (every 1-2 weeks)

Failed Taper

• The patient is unable or unwilling to taper the dose further due to severe pain.

• Some possibilities…• Patient has an underlying opioid use disorder and

cannot tolerate even a small reductions in the opioid dose.

• The taper was done too quickly and/or the patient is suffering from end-dose withdrawal symptoms.

• The patient’s pain condition requires a higher dose.

Now What?

• Consider opioid rotation if patient gets stuck

• Consider Suboxone if patient gets stuck

• Hold the taper, and…

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GUIDELINES: Recommendation #10

For patients with chronic noncancer pain who are using opioids and experiencing serious challenges in tapering, we recommend a formal multidisciplinary program (strong recommendation)

• In recognition of the cost of formal multidisciplinary opioid reduction programs and their current limited availability/capacity, an alternative is a coordinated multidisciplinary collaboration that includes several health professionals whom physicians can access according to their availability (possibilities include, but are not limited to, a primary care physician, a nurse, a pharmacist, a physical therapist, a chiropractor, a kinesiologist, an occupational therapist, an addiction medicine specialist, a psychiatrist and a psychologist).

What should health care providers do when faced with a difficult clinical scenario?

•Form a differential diagnosis

Dr. Joel Bordman

Dependence is inevitable with continuous use

Physical – regions of control of somatic function - locus ceruleus(noradrenergic nucleus) upregulation of cAMP arousal, agitation, nausea, diarrhea, rhinorrhea,

piloerection

Emotional/psychological – reward centershedonia anhedonia

Pain pathwaysanalgesia hyperalgesia

Ballantyne & LaForge, Pain 2007;129:235

Ballantyne et al, Arch Int Med 2012;172:1342

Dependence/addiction develops

through pain treatment

Dependence/addiction develops

through recreational drug use

“Addiction”

• Chronic Multifactorial Disease

• Loss of Control over use

• Continued use despite knowledge of harm

• Compulsive use

• Cravings - (may not be manifest until

tapering/discontinued

• Pestering reluctant doctors• Using opioid to treat pain

• Predominant symptom of withdrawal - pain

• Need to procure opioid• Often use paraphernalia

• Predominant symptom of withdrawal -

anhedonia

Do not accept that anything is wrong

other than pain

Accept that they are addicted

Ballantyne & LaForge Pain 2007;129:235-55

Opioid Seeking Behaviours

GRAY ZONE

ADDICTED NOT ADDICTED

Meets DSM criteria

for addiction

• No lost prescriptions

• No ER visits

• No early prescriptions

• No requests for dose

escalation

• No UDT aberrancies

• No doctor shopping

(PMP)

• Nobody wants to call it

addiction

• It often doesn’t look like

“addiction”

• It is pathological

• It does destroy lives

• It is avoidable, and it is

treatable

Dependence on Opioid Pain Medications

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Addiction (5Cs)

“A primary, chronic, neurobiological disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations.

It is characterized by behaviors that include one or more of the following:Control impaired over drug use

Compulsive use

Continued use despite harm

Cravings”

American Society of Addiction Medicine. Public Policy Statement: Definition of Addiction. 2011.

http://www.asam.org/DefinitionofAddiction-LongVersion.html

Symptoms, Signs & Behaviours Suggestive of OUD

Difficult to Diagnose – Pt fears that opioids will be discontinued with disclosureDx often requires collateral information from family members and observation over time

• Patient’s opioid dose high for underlying pain condition (eg 600 mg MED for low back pain)

• Aberrant behaviours: Running out early, crushing or biting oral tabs, or accessing opioids from other sources

• Strong resistance to tapering or switching current opioid• Importance patient attaches to the drug far outweighs its analgesic benefit

(e.g., “pain is10/10, hydromorphone only takes edge off, but I would die if you stopped it”)

Kahan M and Wyman J. METAPHI. 2017

Symptoms, Signs & Behaviours Suggestive of OUD

• Binge rather than scheduled opioid use

• May be currently addicted to other drugs, e.g., alcohol

• Depressed and anxious

• Deteriorating mood and functioning

• Concerns expressed by family members

• Reports recurrent, frightening withdrawal symptoms (without identifying it as withdrawal: ‘when the hydromorphone wears off, my pain is 12/10, I hurt all over, and I feel horrible’

• May acknowledge immediate improvement in mood after taking the opioid

Kahan M and Wyman J. METAPHI. 2017

Criteria Suggestive of AMTB or Use Disorder

ASAM-APS-AAPM BEHAVIORAL CRITERIA

EXAMPLES OF SPECIFIC BEHAVIORS IN OPIOID THERAPY OF PAIN

Impaired control over use Compulsive use

Frequent loss/theft reportedCalls for early renewalsWithdrawal noted at appointments

Continued use despite harm due to use

Declining functionIntoxicationPersistent over-sedation

Preoccupation with use, craving

Nonopioid interventions ignoredRecurrent requests for opioid increaseComplaints of increasing pain in absence of disease progression despite titration

AMTB Differential Diagnosis

OPIOID RECEPTOR ISSUES

• Opioid-induced hyperalgesia

• Opioid unresponsive pain

• Withdrawal-mediated pain

ORGANIC BRAIN DYSFUNCTION

• Concurrent benzodiazepine use

• Traumatic brain injury

• Confusion around schedules

AMTB Differential Diagnosis

PSYCHOLOGICAL ISSUES

• Personality Disorders - Cluster B

• Chemical coping

• Mood or anxiety co-morbidities

OPIOID USE DISORDER

DIVERSION

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RESPONSE to AMTB or OUD: Enforcement RESPONSE to AMTB or OUD: Engagement

Thank you!

NOUGG Guidelines (2010)CLUSTER 5: Managing Opioid Misuse and Addiction

For patients with chronic non-cancer pain who are addicted

to opioids, three treatment options should be considered:

1. Methadone or buprenorphine treatment (Grade A)

2. Structured opioid therapy (Grade B), or

3. Abstinence-based treatment (Grade C)

Consultation or shared care, where available, can assist in

selecting and implementing the best treatment option

(Grade C)

Structured Opioid Therapy

• Continued opioid prescribing under conditions that limit aberrant drug related behaviours

• Effective, convenient and easier to organize than opioid substitution therapy

INDICATIONS

• Has or is at high risk for opioid use disorder (younger, personal or strong family history of addiction, anxiety or mood disorder)

• Has pain condition requiring opioid therapy

• Only uses opioids supplied by one physician

• Does not alter route of delivery (inject or crush oral tabs)

• Is not currently addicted to alcohol or other drugs

Opioid Replacement Therapy

Substituting an illicit and/or aberrantly used opioid with a longer-acting, less euphoric opioid.

INDICATIONS

• Has an opioid use disorder

• Failed at or not a candidate for structured opioid therapy

• Acquires opioids from multiple sources (e.g. other doctors, friends and relatives, the street)

• Injects or crushes oral tablets

• Currently misusing alcohol or other drugs

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Opioid Replacement Therapy

Improvements are seen in…oDecreased opioid useoMortality / Overdoseo Retention in psychosocial treatment programs.o Social and occupational functioningoQuality of lifeo Reduced HIV/HCV transmission with injection drug useo Reduced HIV transmission by high-risk sexual behaviour

Managing Pain in Patients with OUD or at Risk

• Methadone

• Buprenorphine

• Acute-on-chronic short-acting opioids• Structured (dispensing, visits, UDTs)

• Don’t use drug of choice

• Non-opioid adjuvants

• Interventional modalities

• Non-pharm modalities